The over-all aim of this revised application is to determine whether or not psychoactive drug use in nursing homes has changed over time and to provide information on the extent to which changes in that use can be explained in relation to the proportion of residents on psychoactive drugs, the average drug dosage, shift from one drug category to another, and dosage reduction for residents receiving antipsychotic drugs. In response to the alarmingly high use of chemical restraints as a method of behavior control, the Health Care Financing Administration (HCFA), through its 1990 interpretive guidelines of the Nursing Home Reform Law of omnibus Budget Reconciliation Act (OBRA) (P.L. 100-203) of 1987 is attempting to bring about a reduction by linking drug use to continued facility licensure. However, the guidelines are neither totally prescriptive nor exhaustive, allowing variation in practice and therefore variation in quality of care among nursing home residents. The extent to which staff practice is consistent with the intent of the regulations depends, in part, on the characteristics of the resident. However, staff practice is also influenced by characteristics of the facility in which staff conduct their practice as well as the consultation and educational programs which they receive. To accomplish the project aims, we propose to examine drug use data over a 54 month time period using secondary data on all Medicaid nursing home residents (over 10,000) in all (160) Medicaid licensed nursing facilities in Oregon. Data will be analyzed in two phases. In the first phase estimates on the use of psychoactive drugs over time will be developed and described. In the second phase, hierarchical models will be tested to determine the extent to which facility characteristics and external forces explain changes in staff practice over time. This study will provide information which is needed to profile facilities whose practice jeopardizes the quality of resident care and identify interventions that may be effective in changing that practice. The study will also develop algorithms which can be incorporated into state government's ongoing monitoring responsibilities. The project staff are a multi-disciplinary team of researchers from Oregon Health Sciences University as well as co-investigators and consultants from Benedictine Institute for Long Term Care; Kaiser Permanente Center for Health Research; University of Illinois at Chicago, Department of Sociology and the Sisters of Providence Health Plan of Oregon.